Sept. 2, 2021 -- Headlines of Black Panther star Chadwick Boseman’s death last year shocked the world when it was revealed the actor had died after a secret 4-year battle with colon cancer.
At just 43, the Black actor seemed impossibly young to succumb to a cancer so preventable that some describe it as “the disease no one has to die from.” But as fans publicly questioned how such a thing could happen, doctors quietly acknowledged a stark reality: It happens a lot.
“Chadwick’s death highlighted two little-known aspects of this disease: that colon cancer afflicts the young too, and that Blacks are disproportionally affected both in terms of getting it and dying from it,” says Aasma Shaukat, MD, a professor in the Division of Gastroenterology at the University of Minnesota.
In general, colorectal cancer rates have declined steadily for decades. But that trend stalled and reversed in recent years among people under 55, with rates growing 2% per year since 2012. For context, a millennial has twice the risk of getting colon cancer and four times the risk of getting rectal cancer than a Baby Boomer, according to the American College of Gastroenterology.
Of the 150,000 colorectal cancer cases diagnosed each year in the United States, 12% are in people under 50.
Black men, specifically, remain the most vulnerable group in the United States, diagnosed more often and at later, hard-to-treat stages. Studies show that a Black man is 24% more likely to get colorectal cancer than a white man and 47% more likely to die from it. Black women are also more vulnerable, with risks that are 19% and 34% higher, respectively.
And with COVID-19 lockdowns forcing people to delay in-person doctor’s office visits for much of 2020, health experts worry the numbers will continue to go downhill.
Why Screening Is Key
On the whole, colon cancer is very preventable because of the gold-standard screening tool: colonoscopy.
“If we find a polyp during screening, we can remove it and keep it from ever turning it to cancer,” says Shaukat, noting that some precancerous lesions will grow in the body for years before becoming cancerous. “That gives us a very large window to intervene.”
If colorectal cancer is caught early, the prognosis is remarkably good, with patients having about a 95% chance of surviving 5 years. But once it has spread to organs and tissues, that chance plummets to below 25%, she notes.
Experts credit the decline in the number of cases and deaths among older Americans to the rise of routine colonoscopies, as well as DIY at-home tests that can detect a brewing problem and nudge people to go in for the procedure.
But, says Shaukat, the pandemic “completely derailed colon cancer screening.”
Screenings dropped a whopping 86% in the U.S. as in-person doctor visits ceased and insurance companies suspended elective procedures, including colonoscopies.
In European countries that were affected early on by the virus, the consequence of those skipped tests has already begun to play out, with more people being diagnosed at later stages. Now, researchers fear that’s what’s in store for the rest of the world, with some predicting thousands of additional colorectal cancer deaths to come.
“Our message now is: Do not delay anymore,” Shaukat says. “Get it done.”
Why Black Men Are at Greater Risk
Walter Hickman, an IT professional from Stone Mountain, GA, was 41 years old when he noticed his stool was, as he puts it, “the shape of a canoe rather than a submarine.”
Embarrassed to bring it up, the otherwise healthy father of four kept his observation to himself, even as he went to his doctor for a routine exam and prostate screening.
Three years later, he found himself in the emergency room, doubled over with stomach cramps and constipation. When doctors looked inside, they found a grapefruit-sized mass that had been growing for years. Multiple surgeries later, with a foot of his colon and 12 lymph nodes removed and a dozen rounds of chemotherapy behind him, he is cancer-free.
But he has his regrets, which he shares with young Black men whenever he gets a chance.
He didn’t tell his doctor about his symptoms. He carried on through his busy workaday life, and, wanting to be strong for his new wife and four kids, he ignored subtle signs.
“I used to think rates were higher among Black men because they don’t have good access to health care,” says Hickman. “That is true, but even the ones who do have access can get into trouble.”
Charles Rogers, PhD, and an assistant professor in the Department of Family & Preventive Medicine at the University of Utah’s School of Medicine, studies racial disparities in colon cancer. He says that in addition to diet, lifestyle factors, poverty, and reduced access to good medical care, there are less talked about reasons that Black men are at greater risk: homophobia, a culture of masculinity, and mistrust of the medical system.
In a study that included interviews with Black men ages 45-75 in Minnesota, Ohio, and Utah, Rogers repeatedly heard concerns that colonoscopy, which involves the placement of a flexible tube inside the rectum, was associated with “gay sex” or was not masculine. “The stigma is because of the body part they’re examining,” said one Minnesota study participant.
Participants also brought up the Tuskegee Study, a government-funded research program that withheld treatment for syphilis from poor Black men from 1932 to 1972.
“Those memories run very deep in the Black community, and medical mistrust comes up a lot,” says Rogers.
In another study, published in July 2020, Rogers identified 232 counties as “geographical hot spots” for colon cancer in men under 50. Ninety-two percent were in the South, with the lower Mississippi Delta, west-central Appalachia, and eastern Virginia and North Carolina topping the list.
Several counties in South Carolina, where Boseman was born and raised, made the list. And Black, non-Hispanic men were at particularly high risk of dying young from colon cancer.
“Just like Black people need to have the talk with their sons about sex and being careful of cops, they need to be talking about colorectal cancer and how to prevent it,” Rogers says. “It is not just an old person’s disease.”
Diet, Lifestyle, Environment Play Roles
Racial disparities aside, researchers are working hard to unravel what might be driving increases in colorectal cancer among Gen Xers and millennials, looking at everything from heightened exposure to pesticides and hormone-mimicking chemicals in the environment, to early overuse of antibiotics, to lack of vitamin D-generating sunlight.
“There are so many different candidates, and there is a lot of speculation in the field,” says Nathan Ellis, PhD, an associate professor in the Department of Cellular and Molecular Medicine at the University of Arizona Cancer Center who studies colon cancer risk.
Smoking has been shown to boost risk about 18%, and counties with high rates of early-onset colorectal cancer have higher-than-average rates of smoking.
Eating red or processed meat is another, with every daily 25-gram serving of processed meat (think: a slice of ham) boosting risk by 19%.
Obese people are about 30% more likely to get colon cancer. And some studies suggest that high-fructose corn syrup, ubiquitous in sugary drinks, can fuel its development in animals, even if they are not overweight.
Meanwhile, other under-the-radar factors are increasingly being explored.
“There is a lot of evidence that there is an interaction between the microbiome (the collection of bacteria inside us), epithelial cells that line the gut, and the immune system, and that if it goes wrong, it can influence development of colon cancer,” says Ellis.
For instance, research has shown that sulfide-producing bacteria, which feed on nutrients from an animal-based diet, can fuel inflammation and damage DNA. Other types of bacteria produce byproducts that have been shown to fuel tumor growth.
When such “bad bacteria” outweigh the good, it can create an environment for cancer to thrive, says Ellis.
A lack of vitamin D, a hormone generated in human skin when exposed to sunlight, may also factor in. Studies show that people with higher levels of vitamin D have lower colorectal cancer rates, but research on supplements has yielded mixed results.
Notably, because their skin is pigmented, Black people require more sun exposure to produce the same amount of vitamin D as white people, says Ellis. And young professionals who work indoors all day or live in Northern latitudes where the sun doesn’t rise as high also tend to lack the hormone.
Genes, while adding only about 10% or 20% to the risk of early-onset colon cancer, also play a role.
Regardless of the root causes, experts say screening is the number one weapon against colorectal cancer. And several professional organizations -- most recently the American College of Gastroenterology -- have changed their recommendations to advise people to start getting screened at age 45 instead of age 50.
Rogers has also launched an initiative to get barbers to talk with their clients about the importance of getting screened.
“Barbers have relationships with their clients for years and often know more about them than their significant others do,” he says.
Rogers also hopes that the color blue in March, the color and month for colon cancer awareness, will someday be as recognizable as pink in October, the color and month for breast cancer awareness.
“This is a preventable, beatable, and treatable disease that does not get much attention until someone famous tragically dies,” he says. “That’s a trend we need to change.”
Colon Cancer Screening 101
While colonoscopy is by far the best-known way to screen for colorectal cancer, several noninvasive do-it-yourself screening tools have also emerged in recent years.
“The best screening tool is the one that gets done,” says Rogers.
Read on for a look at three screening tools and how they work.
Fecal immunochemical test (FIT): Checks swab of stool for hidden blood in the stool, coming from polyps or cancers. Requires no pre-test diet, can be done at home, and tends to be inexpensive. But it can test positive for other reasons (hemorrhoids, ulcers, other conditions). If it comes up abnormal, doctors recommend a colonoscopy. Recommended: Once a year.
Stool DNA test (Cologuard): At-home test that looks for abnormal sections of genetic material from cancer, in addition to blood in the stool. Tests full stool sample. If the test is positive, a colonoscopy is recommended. Recommended: Every 3 years. Insurance may or may not cover it, depending on results.
Colonoscopy: In-office procedure in which the doctor looks at the entire length of the colon and rectum with a flexible tube about the width of a finger with a light and small video camera on the end. Special instruments can be passed through the colonoscope to take a sample or remove any suspicious-looking areas such as polyps, if needed. You’ll need sedation and a special pre-appointment diet to empty the bowel. Recommended: Every 10 years.
Source: American Cancer Society